Exhaustion of Process. The foregoing procedures and process are mandatory and must be exhausted prior to:
Exhaustion of Process. The foregoing procedures and process are mandatory and must be exhausted prior to: the establishing of any litigation or arbitration, or any administrative proceeding regarding either any alleged breach of the Group Agreement or EOC by HMO, or any matter within the scope of the Complaints and Appeals process.
Exhaustion of Process. The foregoing procedures and process are mandatory and must be exhausted prior to: The establishing of any litigation or arbitration, or any administrative proceeding regarding either any alleged breach of the Group Agreement or Certificate by HMO, or any matter within the scope of the Complaints and Appeals process. DISPUTE RESOLUTION Any controversy, dispute or claim between HMO on the one hand and one or more Interested Parties on the other hand arising out of or relating to the Group Agreement, whether stated in tort, contract, statute, claim for benefits, bad faith, professional liability or otherwise ("Claim"), shall be settled by confidential binding arbitration administered by the American Arbitration Association ("AAA") before a sole arbitrator ("Arbitrator"). Judgment on the award rendered by the Arbitrator ("Award") may be entered by any court having jurisdiction thereof. If the AAA declines to administer the case and the parties do not agree on an alternative administrator, a sole neutral arbitrator shall be appointed upon petition to a court having jurisdiction. HMO and Interested Parties hereby give up their rights to have Claims decided in a court before a jury. Any Claim alleging wrongful acts or omissions of Participating or non-participating Providers shall not include HMO. A Member must exhaust all Complaint, Appeal and independent external review procedures prior to the commencement of an arbitration hereunder. No person may recover any damages arising out of or related to the failure to approve or provide any benefit or coverage beyond payment of or coverage for the benefit or coverage where (i) HMO has made available independent external review and (ii) HMO has followed the reviewer's decision. Punitive damages may not be recovered as part of a Claim under any circumstances. No Interested Party may participate in a representative capacity or as a member of any class in any proceeding arising out of or related to the Group Agreement. This agreement to arbitrate shall be specifically enforced even if a party to the arbitration is also a party to another proceeding with a third party arising out of the same matter.
Exhaustion of Process. The foregoing procedures and process are mandatory and must be exhausted prior to the establishing of any litigation, arbitration or any administrative proceeding regarding either any alleged breach of the Group Agreement or Certificate by HMO, or any matter within the scope of the Complaint and Adverse Determination process. The foregoing procedures and processes are not in lieu of any statutory rights Members may have to institute litigation, arbitration or administrative proceedings. If Subscriber’s health plan is governed by the Employee Retirement Income Security Act (ERISA), Member has the right to bring civil action under 502(a) or ERISA.
Exhaustion of Process. You may contact the New Jersey Department of Banking and Insurance to file a complaint/appeal or, request an investigation of a complaint/appeal at any time. You are not required to exhaust the Level One and Level Two appeals process before contacting the New Jersey Department of Banking and Insurance. Unless serious or significant harm has occurred or will imminently occur to you, you must exhaust an appeal through the Independent Health Care Appeals Program before you establish any litigation; arbitration; or administrative proceeding; regarding an alleged breach of the policy terms by HMO; or any matter within the scope of the appeals procedure. In the event that HMO fails to comply with any of the deadlines for completion of the Level One Appeal or Level Two Appeal, or in the event that HMO, for any reason, expressly waives its rights to an internal review of any Appeal, then the Member and/or Provider shall be relieved of their obligation to complete the HMO internal review process and may, at their option, proceed directly to the external appeals process set forth in section D below.
Exhaustion of Process. You may contact the New Jersey Department of Banking and Insurance to file a Complaint/Appeal or, request an investigation of a Complaint/Appeal at any time. You are not required to exhaust the Level One and Level Two Appeals process before contacting the New Jersey Department of Banking and Insurance. New Jersey Department of Banking and Insurance Office of Managed Care Consumer Protection Services P.O. Box 329 Trenton, New Jersey 08625-0329 Before filing a Level One or Two Appeal with Aetna, you or your authorized representative, may also contact the New Jersey Office of Insurance Claims Ombudsman if you are dissatisfied with the decision reached by Aetna.
